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Thursday, August 09, 2007

The following are all taken from Dr. Theodore Dalrymple's article, "Health of the State"in the Aug. 13, 2007 edition of National Review. . Dr. Dalrymple worked as part of the British National Health Service for 20 years.

To avoid public criticism of the NHS in Britain is like avoiding evidence of dictatorship in North Korea: It is possible only for the willfully blinkered.

In its most successful period, the state-run NHS was possibly the least bureaucratic system in the world: far, far less bureaucratic than the American free-enterprise, or increasingly corporatist, system. This was because doctors were still the most powerful group within it...in return for their salary, the doctors had effective control of most things, including who got what. They neither knew nor were interested in what anything cost: Rationing was informal and implicit rather than formal and explicit as it is now, and quite without bureaucratic controls or costs. The NHS also had the cultural capital of the hospital system that existed before it.

But there were problems from the first. Chief among them was that capital expenditures came to an immediate halt after the NHS was begun

EMD: so no new hospitals, new infrastructure, nothing.

Fewer hospitals were opened in the first half-century after the start of the NHS than in the 1930s alone. The result has been that the vast majority of NHS hospitals are now run down institutions...the one in which I worked was a 19th-century workhouse.

The NHS was founded on the supposition that, as the population grew healthier thanks to its socialized ministrations, health-care costs would decline. The exact opposite was the case, of course: Not only did health care become vastly more expensive, but the population aged fast and needed ever more such health care. Government funding form general taxation always limped behind what was necessary to keep up with demand and with technological developments.Waiting lists for expensive investigations and procedures lengthened as shortages became even greater. Emergency care remained good, but at the expense of almost everything else.

Expenditure has increased 300 percent in ten years, but most people believe that very little, if anything, has changed for the better, and some for the worse...[h]e who pays the piper calls the tune, at least eventually. For many years tye government refrained from interfering very obviously in the running of health services in Britain, but it has increasingly set targets for hospitals and doctors to meet, and interfered with the minutiae of medical practice, laying down who must be treated first, and with what treatment.

Manager in the NHS now often decided on the priority of patients' operations, not on clinical grounds, but according to government targets; they scour the wards for patients they believe can be discharged; they set priorities in the emergency rooms, again not according to clinical criteria, but in according to the need to meet government targets. Manager now screen all referrals to psychiatrists and decide which patients the psychiatrist should see, which is a fundamental breach of medical ethics. A central organization, the National Institute for Clinical Excellence, lays down what drugs may be prescribed by doctors in the NHS.Now of course problems such as the ones I have just mentioned exist in all systems where payment for medical services is made by third parties. But to make a single, all-powerful third party--and the government at that--responsible for all such payment is to magnify and compound the problem.

Variation in morbidity and mortality between the social classes in Britain is as great as it was before the NHS was instituted, and possibly greater. [Michael] Moore [in his film Sicko] does not tell us about waiting times in the NHS. (I remember one patient, a man of 70, who had had a hernia diagnosed seven years previously. HE was put on a waiting list for an operation, but hearing nothing from the hospital for seven yearswrote a letter to enquire when he would have his operation. He received a letter telling him to wait his turn. In a system such as the NHS, an apparently rational and just reason not to operate on him--i.e., there was something more urgent to be done--can always be found.) He also fails to tell us there has been a rising tide of public dissatisfaction with the NHS; that 75 percent of senior doctors in Britain want to retire as soon as possible...that the results in the NHS for many cancers and heart conditions are among the worst in the Western world; that the hospitals are filthy and that the rates of hospital infection are also among the highest.

Before the NHS...75 percent of the population had private medical insurance, and they couldn't all have been rich

It is clear that the American systems leave a lot to be desired--as do most systems. It is expensive and not particularly effective when viewed from the point of view of public health. It has strengthens...for example, that it is by far the most innovative and performs by far the most important medical research in the world. Nor is it even a complete public-health disaster: life expectancy at birth in the Untied states increased from 75.4 years in 1990 to 77.5 in 2003.